Under limited supervision, applies medical necessity guidelines in making authorization determinations for inpatient admissions, concurrent, and retrospective reviews in collaboration with physician reviewers. Applies evidence-based discharge planning so that patients have a safe and timely transition to next appropriate level of care.Note: This position allows you the flexibility to work at home.Responsibilities
Evaluates clinical information using established national decision support criteria, company policies, and individual patient considerations to ensure the provisions of safe, timely, and appropriate covered healthcare services.
Independently conducts basic to complex post-acute care admissions, concurrent, and retrospective reviews, including skilled nursing facility, acute physical rehabilitation, and long-term acute care hospitals, to ensure compliance with criteria guidelines, member eligibility, benefits and contracts.
Plans, implements, and documents, discharge planning activities based on the members’ specific clinical condition, health plan benefits, and optimal care delivery. Acts as a resource to the provider community, explaining processes for accessing the Company’s website to identify network providers for next level of care and post-discharge follow-up care
Promotes effective resource management by directing member care to accessible cost-effective post-acute network providers and services at appropriate level of care. Coordinates with other Pharmacy and Care Management departments to facilitate the timely provision of covered health care services.
Participates with designated external vendors and Assistant Medical Directors, social workers and case managers to determine potential high dollar member costs, discharge planning interventions that ensure delivery of consistent and quality health care services.
Keeps up to date on utilization management regulations, policies and practices.
If assigned to Preceptor/Trainer task: Orients, trains and provides guidance to more junior or less experienced staff. Supports implementation of new procedures, processes or clinical systems.
Performs other duties as assigned.
Qualifications
Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor’s degree preferred.
3 years as a Registered Nurse with a combination of clinical and or utilization/case management experience, preferably in the health insurance industry.
Acute inpatient level of care in Medical/Surgical/Critical Care/ ambulatory care experience preferred.
Registered Nurse with current State of Ohio unrestricted license.
Intermediate Microsoft Office skills and proficiency navigating windows and web-based systems.
Knowledge of, and the ability to apply fundamental concepts related to HIPAA compliance and related regulations.
Knowledge of clinical practices and efficient care delivery processes.
Ability to occasionally travel offsite for on-going training.
Ability to occasionally work weekends and extended hours as needed.
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:A Great Place to Work:
We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
Discounts at many places in and around town, just for being a Medical Mutual team member.
The opportunity to earn cash rewards for shopping with our customers.
Business casual attire, including jeans.
Excellent Benefits and Compensation:
Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
An Investment in You:
Career development programs and classes.
Mentoring and coaching to help you advance in your career.
Tuition reimbursement up to $5,250 per year, the IRS maximum.
Diverse, inclusive and welcoming culture with Business Resource Groups.
About Medical Mutual:Medical Mutual’s status as a mutual company means we are owned by our policyholders, not stockholders, so we don’t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.There’s a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.We’re not just one of the largest health insurance companies based in Ohio, we’re also the longest running. Founded in 1934, we’re proud of our rich history with the communities where we live and work.At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.#LI-REMOTETitle: Medicare Nurse ReviewerLocation: OhioRequisition ID: 2400438
